Not all men with symptoms of an enlarged prostate have an enlarged prostate. What’s going on?

When men middle-aged or elderly men have some difficulty with urination, their doctor’s attention will usually focus on their prostate – the gland that encircles the pipe that takes urine from the bladder to the outside known as the urethra. An enlarged prostate can impinge on the outflow of urine from the bladder and therefore cause symptoms such as frequency (needing to pass water frequently), nocturia (passing urine at night), hesitancy (having difficult getting urination going) and ‘post micturition dribbling’ (‘leaking’ after urination). See the diagram below for the relevant anatomy.


I read a recent review of the management of ‘lower urinary tract symptoms’ in men published in the British Medical Journal [1]. No surprisingly, it focuses a lot on prostatic enlargement (the most common for of which is non-cancerous and usually referred to as ‘benign prostatic enlargement’ or ‘BPH’).

However, I find it’s not uncommon for men to have urinary symptoms that do not stem from the prostate. In other words, I’ve seen men in practice who have symptoms of ‘BPH’ but have no evidence of BPH. This phenomenon, I think, does not get the recognition it deserves.

I was therefore interested and pleased to see the inclusion of the following paragraph in the BMJ piece:

In addition, although lower urinary tract symptoms are associated with urinary flow and prostate size, there is substantial evidence that men can have symptoms even in the absence of BPH, enlarged prostate on physical examination, or abnormal urinary flow rates. This is partly because lower urinary tract symptoms can be caused by multiple mechanisms, including prostate and bladder smooth muscle tone and contractility. Moreover, the prevalence of lower urinary tract symptoms in women is not too dissimilar to that in men. Thus, although lower urinary tract symptoms in older men are often attributed to BPH, clinicians should consider other causes in their diagnosis and evaluation…

Notice this sentence in particular: “the prevalence of lower urinary tract symptoms in women is not too dissimilar to that in men.” Women don’t have prostates, so what causes lower urinary tract symptoms here, and could there be similar issues in some (perhaps many) men?

In women, urinary symptoms are often recognised to be the result of dysfunction in the bladder. Here, the bladder (which is essentially a muscular bag) can be ‘overactive’, and this can cause a symptom known as urgency, which basically means there is strong desire to urinate and the need to get to a toilet quickly. It’s not uncommon for individuals with this symptom to get caught short, giving rise to something known as urge incontinence.

Women are usually the prime suspects for urge incontinence, because childbirth is believed to have the ability to change the muscles at the base of the pelvis (pelvic floor muscles) in a way that can impair continence. However, I think bladder dysfunction is common in men, and often gets missed because of we doctors’ tendency to focus on the prostate.

By way of example, I saw a man some years ago with urinary symptoms, mainly of the “urgency” type. He had had his prostate investigated, and it had been concluded that while this was moderately enlarged, this might not actually explain his symptoms. Actually, in my opinion, his symptoms suggested an overactive bladder, which means his enlarged prostate may well be a red herring.

Over the years, I have discovered that an overactive bladder is very often related to a deficiency of the mineral magnesium. Magnesium is very important for normal muscular function, and a deficiency of it can cause muscles to be prone to spasm. So, this may cause the bladder to be overactive, but it can also cause symptoms in other muscles too including the skeletal muscles. Symptoms I look out for here are a tendency to cramp, tight muscles and ‘restless legs’ (a problem which tends to be most obvious when individuals are trying to get to sleep in bed at night).

I generally recommend that individuals with symptoms of an overactive bladder try upping their magnesium intake, and this is especially the case where there are other symptoms suggestive of magnesium deficiency. Nuts are a good source of magnesium, though for speedier results I find it helps to supplement too at a dose of about 400 mg of elemental magnesium per day.


1. Hollingsworth JM, et al. Lower urinary tract symptoms in men. BMJ 2014;349:g4474

14 Responses to Not all men with symptoms of an enlarged prostate have an enlarged prostate. What’s going on?

  1. Don 22 August 2014 at 12:54 pm #

    Thank you for this one. I have suffered urgency for more than a decade (now 66) initially accompanied by most of the symptoms you mentioned: hesitancy, dribbling, and frequent nighttime trips to the john. My doctor didn’t feel any prostate enlargement but remarked that the prostate can be enlarged in the back, Because the symptoms were pretty severe he prescribed Flomax which cut most of the symptoms (although not the night trips) but exacerbated ortho static hypo-tension so I eventually switched to Avodart. Over the years I also had a lot of problems with leg cramping and RLS and read about a possible magnesium link online. I started magnesium supplements and got significant relief from the RLS symptoms. At about this time I also started reading you and others which led me to quit statins, quit sugar and processed foods, and drop about 18% of my body weight. Encouraged by that I experimented with dropping the Avodart and surprise – no change. The original symptoms did not recur although I still take a few trips to the john at night. It is nice to know that magnesium could have been the culprit all along. Although I also speculated that the severity of the initial symptoms may have signaled a UTI since the nightime trips have remained a factor that never changed.

    I discussed the prostate/urinary situation at every annual physical over the years because the potential to return to the original symptoms worried me. None of the three doctors I saw over that period suggested anything other that my prostate as a possible culprit. I am thankful to you and others who help people like me find sources of help with our problems. But it is distressing that we (patients) have to turn to the Internet for advice. Dr Google can be very good but can also lead us astray into pseudo science and dead ends. It can be difficult for a lay person to tell the difference.

  2. Soul 22 August 2014 at 1:03 pm #

    To mention another possible cause of frequent urination, as it’s one I’ve had to deal with off and on over the years, I’m not sure what is happening but have a theory. I have an inflamed colon or IBD condition. I’ve noticed that often when I’m having more frequent colon issues, I’m likely to also experience a bloated gut. Basically my pants become tighter. I’ll also feel cool when this happens, and if in a cool room will find myself needing to frequently need to use the restroom. I had an embarrassing experience with this recently at a dentist appointment. My gut was bloated, the dental room cool, and as a result I’m needing to use the restroom constantly. Over and hour I must have used the bathroom a half dozen times.

    Here of late, the bloating is gone, I feel warmer, and I find myself on the opposite side of the spectrum. I rarely need to use the bathroom. My theory of what is happening to me is my colon when in trouble or stressed retains water or maybe inefficiently removes water from the colon. Kind of nice of late not having the bloating and frequently bathroom breaks. As a side note also my appetite has decreased greatly. Imagine if this continues water and food bills will be less next billing.

  3. M. Cawdery 22 August 2014 at 2:35 pm #

    I had a massive prostate – never had a positive PSA. Had some removed – not cancerous – just a b…….. nuisance. The PSA test is not accurate but in the US is a massive money maker.

    Gigerenzer, Gerd (2014-04-17). Risk Savvy: How To Make Good Decisions (p. vii). Penguin Books Ltd uses this to show how “survival time” used in cancer treatment has no relationship to mortality rate in the condition.

  4. TJHuber 22 August 2014 at 2:58 pm #

    Just for what it’s worth. Both my wife and I have discovered, munch to our joy, that cur cumin helps the “urgency feeling” greatly. We have recommended that to our doctors and had positive feedback from both of them. Try it! Good luck!

  5. Vanessa 22 August 2014 at 3:03 pm #

    When my mother was alive, she (aged 93 then) had problems with urge incontinence and responded very well to magnesium supplementation that I sourced for her. The GP was ready to dose her with who-knows-what pharmaceuticals which we managed to avoid very successfully. I’m not surprised that many men are misdiagnosed too – I get the impression that once a doctor starts to listen to a patient’s symptoms, they immediately think of a diagnosis and then stop listening any further. That’s certainly been the case whenever I’ve been to the GP which I don’t very often – try and avoid them like the plague, if I’m honest!!

  6. Sharon Burress 22 August 2014 at 4:24 pm #

    You have validated a “theory” of mine I have held for a while now. I have urge incontinency and when I see those prostate infospots on TV directed to men about the urinary difficulties, I kept thinking, ” I don’t have a prorate and I have all those symptoms. I wonder if those doctors are overlooking the obvious, the bladder.”
    I want to thank those who responded here. I should have thought of magnesium and I just started taking curcumin and, as a matter of fact, I have NOT had any urgency problems recently! Huh! Awesome. I will add magnesium, too, I am giving it to my husband for restless legs and other symptoms (and lab results) of mag deficiency. Thank you, guys!

  7. Dave Sander 22 August 2014 at 8:00 pm #

    One of the things I noticed was not enough nerve signaling to keep bladder control. While the magnesium is a good idea (was already taking that) I also came across research where pumpkin seeds or proteins were used to improve the signaling of the nerves controlling the bladder. This condition is possibly related to the changes in dropping hormone levels and nerve sensitivity with age. The pumpkin seed worked rather nicely and my bathroom trips are now reduced by 80%. I’d guess that the bladder became larger once the nerves started working again.
    This would be another cause probably not diagnosed by doctors with much frequency.

    Have read theory that the main cause of BHP is actually high estrogen levels in men and not high DHT levels. Some clinics use DHT to treat the prostate since DHT reduces estrogen levels.

  8. Nigel Kinbrum 24 August 2014 at 6:35 pm #

    “Women don’t have prostates…”
    I don’t quite know how to say this, but…

  9. George Henderson 25 August 2014 at 5:53 am #

    Good article. Also consider UTI as cause. Does hibiscus tea or l-mannose improve symptoms? Does sugar or ascorbic acid worsen them? The irritation or inflammation produced by bacteria feeding on sugars in bladder and tract can produce sensation of urgency.

  10. kathy 25 August 2014 at 6:46 pm #

    I’ve had similar problems for some years, and eventually went for a full UT check at Addenbrookes. I’ve been on medication for several years now, tolterodine tartrate at the moment., and they are truly life-style changing. I cannot understand the reluctance to prescribe these widely as now I can walk away from loos for hours, cough, run and be relaxed and basically normal. It would restore dignity to many older people if it was treated in a less embarrasing way by society, and would save ££££££££ in continance aids..

  11. Mark. 25 August 2014 at 11:34 pm #

    I’m taking small doses of magnesium citrate brine laxative as a Mg supplement. The dose does matter: too much and it certainly acts as a laxative, but it’s cheap and easily available. I suppose I should aim for an exact dose and measure it carefully instead of just having a sip now and again…

  12. Janet S 27 August 2014 at 12:04 pm #

    I have found caffeine intake to be directly related to urgency. Can’t believe the difference cutting right down on caffeine made. I just seem to have become sensitive to it suddenly, I cut down because of palpitations and was delighted to discover the improvement in bladder function.

  13. Caroline 28 August 2014 at 10:26 am #

    Interesting. A friend introduced me to a really useful thing for bladder problems: waterfall d-mannose. I expect it’s only useful for UTIs but as it seems to be so harmless (except for a high sugar content!), I don’t mind taking a little when I first begin to feel something amiss.


  1. Not all men with symptoms of an enlarged prostate have an enlarged prostate. What’s going on? « - 28 August 2014

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